Page 46 - Q BULLETIN, Ministry of Health Malaysia, VOLUME 1, NO. 31 (SUPPLEMENT 1), JAN-DEC 2022

Q Bulletin, Volume 1, No. 31 (Supplement 1), Jan - Dec 2022
th
11 National QA Convention, 4 – 6 October 2022
PP-08

Reducing the Percentage of Medication Error (ME) Involving Antibiotics Requiring
Renal-Dose Adjustment in Orthopaedic Ward Hospital Melaka

Wong SW, Nur Diniah S, Loh LY, Low SH, Tan PX
Pharmacy Department, Hospital Melaka, Melaka

SELECTION OF OPPORTUNITIES FOR IMPROVEMENT:
One of the most crucial aspects of patient safety is medication safety. A pilot study conducted in Hospital
Melaka in December 2020 has shown that the incidence of ME involving antibiotics requiring renal dose
adjustment in Hospital Melaka was 8.7%.

KEY MEASURES FOR IMPROVEMENT:
The indicator for this study is the percentage of ME involving antibiotics requiring renal dose adjustment in
the Orthopaedic Ward with the standard of 0 ME.

PROCESS OF GATHERING INFORMATION:
The intervention studies were done from 22/2/2021 to 5/3/2021 (cycle 1), followed by 8 to 21/4/2021 (cycle
2), to evaluate the effectiveness of the remedial measures. Prescriptions of antibiotics requiring renal-dose
adjustment were screened and those with ME detected were reported in Medication Error Reporting System
(MERS) Form.

ANALYSIS AND INTERPRETATION:
The post-remedial studies showed a reduction in the number of ME from 7.7% (cycle 1) to 0% (cycle 2). The
contributing factors identified were inadequate knowledge among healthcare workers, an incomplete prescribing
policy of antibiotics and incomplete Standard Operational Procedure (SOP) in dispensing antibiotics.

STRATEGIES FOR CHANGE:
An antimicrobial renal adjustment quick guide was developed and placed in the patient’s medication profile.
Prescriptions were amended by adding a column for creatinine clearance and hemodialysis status. Continuous
medical education among healthcare workers was carried out periodically.

EFFECT OF CHANGE:
ABNA shows a reduction in the percentage of ME detected. All healthcare workers are more alert to check for
patients’ renal profiles upon prescribing, preparing, dispensing and administering antibiotics to patients.

THE NEXT STEP:
To standardise prescription form with additional columns for creatinine clearance and dialysis status for all
wards in Hospital Melaka and eventually nationwide.

42